Can Small Practices Survive MACRA?

By CMS' own accord, the outlook for small practices in the first year of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is bleak.

In its proposed rule for MACRA implementation, CMS projected that 87 percent of participating solo practices will face a negative financial adjustment in year one of MACRA, equating to a total of $300 million lost. The numbers aren't much better for practices with 2 to 9 eligible docs, nearly 70 percent will face a negative adjustment, totaling lost revenue of $279 million.

It's no wonder that many physician advocacy groups, such as the American Medical Association, are voicing numerous concerns about how MACRA will be implemented and the timeline in which it will be rolled out. Currently, practices will have to start complying with MACRA guidelines on Jan. 1, 2017, although CMS has suggested that date may be pushed back.

With this all occurring, it'd be easy to say that MACRA is a pipe dream for practices. While many undoubtedly feel that way, there are some that have a more positive outlook. We spoke with two forward-thinking small practices that have already worked in value-based care, to share their thoughts on whether small practices can survive MACRA.

"[Yes.] In a sense, small or mid-sized practices, if they partner with the right people, they are more nimble than big-sized practices. There is a cost benefit trade off to being small or big. The big guys have more resources, but changing a huge system is difficult ... The big guys, they have difficulty even making the decision who to partner with [on value-based care]. The small or mid-level guys, they don't have the cash resources or even the attention span to create their own chronic care management processes, to hire staff they are not already doing. A lot of groups will say you can add this into your work flow without adding staff. That is complete garbage. It's not true. Everyone knows it … So the small practices don't have the money upfront or the bandwidth … but if they partner with the right person, they can move much faster than the big guys can move … The future of the [Merit-Based Incentive Payment System] [is] dismal for small practices that don't partner with the right folks. They will go out of business. If they do partner, the future is bright for them."

"In talking to some of my colleagues … there is skepticism [that] this is not ever going to work. There are too many variables. It's easy to say, you saw a patient, I'm going to give you $85. Trying to develop some of the parameters of some of the return from value-based care and how you divide those figures up, that's really difficult. I think Medicare is going to realize it's not an easy thing to do. It's not as cut and dry as fee for service. Fee for service has its faults, as we have seen, but it is a well-defined reimbursement. That's pretty easy. I'll say this though … we're going from shared savings to shared risk … and one guy I was talking with, he thinks the final step should be patient risk. Patients should have some skin in the game. That would be the third and final step and I think would give us the most improvement in cost savings over time. If MACRA can somehow bring that on, it would have the best chance of gaining traction and being something worthwhile going forward."

Gabriel Pernais managing editor for Physicians Practice. He can be reached at [email protected].